Dáil Éireann - Volume 343 - 02 June, 1983
Estimates, 1983. - Vote 48: Health.
Minister for Health (Mr. B. Desmond) Barry Desmond
Minister for Health (Mr. B. Desmond): I move:
That a sum not exceeding £978,602,000 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December 1983, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that Office, including grants to Health Boards, miscellaneous grants and a grant-in-aid.
The World Health Organisation have become increasingly concerned, not alone about the escalating costs of health services throughout member nations, but also as regards the strategy which should be adopted to safeguard the health of the populations. The organisation advocate a decreasing emphasis on expensive technology and a concentration on—health as a way of life; the prevention of ill-health; and community care for all.
The organisation advocate a reappraisal of life styles so as to bring about the awareness of the injury to health that results from excesses of various kinds; increased attention to the prevention of disease; and the development of primary care services with emphasis on the role of a caring community.
The World Health Organisation's strategy merits serious consideration by all member states. However, significant changes in the use of resources cannot be brought about overnight. Besides, hospital services must be maintained at a level commensurate with need and thus the scope for shifting resources from institutional to the community area is extremely limited in the short term. This is particularly the case in the present difficult financial situation which rules out the prospect of extra funds in the immediate  future which could be applied to develop community services. Our basic approach as long as current financial difficulties persist must be to contain expenditure on all services within budgetary levels. In the hospital area this will involve the regulation of activity to the level dictated by available funds. This will not be easy, but it is inescapable if expenditure is to be controlled.
The gross non-capital provision in the Estimate amounts to £1,009.102 million. Allowing for Appropriations-In-Aid at £83.5 million the net non-capital grant provision is £925.602 million.
The net non-capital grant provision represents an increase of about £79.5 million on the out-turn for 1982. A further £7.53 million is included for Health in Vote 50 (Increases in remuneration and pensions) to meet the three months' arrears portion of the 1982 agreement on pay in the public services.
The capital provision included in the Estimate amounts to £53 million.
The policy decisions taken by the previous Government in relation to departmental allocations were reflected in the original published Estimate for Health.
The revised Estimate now before the House shows a reduction of £10.3 million on the non-capital side, allowing for the inclusion of a provision of £3 million in the later Estimate for budget increases in rates of allowances, as compared with the earlier Estimate.
Most of the policy decisions which were reflected in the earlier Estimate have been maintained. The only exception is that the decision taken by the previous Government to introduce public ward and out-patient charges has not been implemented. The resultant loss of income estimated at £13 million together with the cut of £10.3 million meant that corresponding savings totalling £23.3 million had to be achieved. The savings are expected to be realised through savings on drugs costs, including adjustment of the drugs refund scheme and a reduction of £5 million on institutional budgets. The savings have been reflected in the 1983 allocations which have been approved for health agencies.
The non-capital expenditure on health  services in 1983 is estimated at £1,070 million in gross terms, or £1,013 million taking account of income from various sources. This figure represents about 7.7 per cent of GNP. The net estimate of £1,013 million comprises £663 million in respect of pay, £297 million in respect of non-pay, excluding cash allowances, and £53 million in respect of cash allowances.
The very major increase in expenditure on health services in the last decade — it has increased almost tenfold since 1972-73 — has been adverted to time and time again. It must be remembered, however, that while the increases in costs were due largely to pay and price increases, substantial amounts were applied to developing and improving health services. Among the major achievements in the last decade were substantially improved services for mentally handicapped persons; development of community psychiatric facilities which have made it possible to care for many psychiatric patients in the community rather than in an institutional setting; development of welfare elements in the health services such as children's services, home help services and meals on wheels together with improvements in welfare allowances; introduction of a choice of doctor scheme for persons in the lower income group; a substantial increase in the numbers of consultant and other medical staff together with corresponding increases in nursing, para-medical and other staff resulting in improved diagnostic and care facilities; introduction of new treatment techniques, accompanied by sophisticated technology in acute hospitals; the extension of eligibility for free hospital services to the entire population.
There is no disputing the fact that the quality and scope of our health services have shown a vast improvement in the last ten years.
There has been much criticism of the manner in which health services resources have been deployed. It has been contended that too high a proportion is spent on hospital services to the detriment of community based services. The figures are certainly revealing. If we  turn to the programme and services presentation of estimated health services expenditure in 1983, as set out in the appendix to the published Health Estimate, we find that £726 million, or about 71 per cent of the gross expenditure this year, will be applied to institutional services; and £237 million, or about 22 per cent of the total, will be applied to community services. The balance of the expenditure is taken by ambulance services, superannuation payments, research and administration charges. The actual amounts spent and the percentages of total expenditure used by each of the various programmes are as follows:—
The absence of extra funds for development purposes means that no developments will be possible unless funds can be released from the overall resources at present available. It is imperative, therefore, that all services be appraised on an on-going basis to identify opportunities for eliminating or modifying services and for improving efficiency. Work in this area is under way in my Department.
Last January I circulated to Deputies copies of the most recent volume of statistical information relevant to the Health Services. The information in this is divided into sections, each of which deals with one of the main health programmes or another aspect of the health service. Deputies will find this a useful aid to understanding what is happening in the health service. I will refer later to the different programmes but first I should like to refer to certain vital and health statistics which are of particular importance.
The section of the population aged  under 15 or over 65 is the section which makes the major demands on the health services. The 1979 census of population indicated that people in this section made up 41.3 per cent of the population of the country. This is higher than the corresponding percentage for any of our EEC partners.
The Irish birth rate was 21.0 live births per 1,000 population in 1981 during which 72,355 births took place. This rate is by far the highest birth rate in the EEC. Over 99 per cent of these births take place in hospitals.
One of the important indicators of the general state of health of a community is the infant mortality rate. This has declined from 30.5 deaths of children under one year old per 1,000 live births in 1961 to 18.0 in 1971 and in 1981 it was 10.6.
In 1981 there were 560,000 admissions to acute public hospitals or 163 per 1,000 of the population. This area is being closely examined in order to identify any potential areas of saving in what is a very expensive part of the health service.
The population is now divided into three categories for purposes of eligibility for health services.
Category I consists of persons with full eligibility. These are persons who are unable to afford general practitioner services for themselves and their dependants without undue hardship. Persons in this category are entitled to the full range of health services without charge and they are issued with medical cards for presentation when services are needed.
Category II are persons, other than those in category I, whose income in the year ended 5 April 1983 was less than £11,000. Persons in this category are entitled, without charge, to hospital services as in-patients in public wards or as out-patients at public clinics and to maternity and infant welfare services. They are also entitled to avail of the drugs refund scheme, which ensures that nobody will have to meet excessive costs for prescribed medicines.
Category III consists of those persons whose income in the year ended 5 April, 1983 was £11,000 or more. Persons in this category are entitled to the same hospital  services as those in category II except that they are liable for the fees of the consultants involved in their treatment. They are also entitled to avail of the drugs refund scheme.
In effect, the £11,000 income limit is the dividing line above which persons are required to pay the fees of hospital consultants. This limit had been £9,500 but I have increased it to £11,000 with effect from 1 June. I am currently giving consideration to the question whether this limit might be abolished entirely. To do this would mean that everybody would be free of the worry of having to meet hospital costs at a time when their ability to do so may be at its lowest. It would also have major implications for other aspects of the health service such as the interests of the medical profession, the Voluntary Health Insurance Board, the health contributions scheme and the relative use of public and private hospitals. These are matters which will need further consideration and consultation before any final decision is made.
Persons liable for consultants' fees or who wish to make private arrangements for services may insure against the cost of these services with the Voluntary Health Insurance Board. To give an example, in the case of a married couple with three or more children who are insured under the V.H.I. boards plan B — the most popular plan — the group subscription payable is about £315 a year. When income tax relief at the standard rate is taken into consideration, the cost is reduced to about £205 a year or about £3.90 a week. The care provided includes the cost of maintenance, cover against consultants' fees in the minimum basis recommended by the VHI board, and benefit related to certain out-patient expenses including prescription costs, doctors' fees and specialist consultation fees.
As Deputies are no doubt aware, health boards are responsible for collecting health contributions, and, indeed, the youth employment levy and the tax levy, from the farming population. Down through the years farm income for the purpose of health contributions was determined on the standard basis of farm  valuation and a multiplier, but in July 1982 the High Court ruled that determining income on this basis was contrary to the Constitution. To cope with this situation, in February 1983 I amended the relevant regulations to provide that for this purpose farmers' income will be determined on profits or gains from farming activities less expenses actually incurred in earning these profits. This means that farmers' income and the health contribution payable will be determined on the same basis as for self-employed persons. Similar arrangements have been made in respect of the other two levies.
This new situation, however, has raised the question of whether health boards are the most suitable agencies to collect health contributions and the other levies from farmers. This does involve some element of factual assessment of farm income by health boards and, of course, the overall position has changed in that, from the current year, liability for income tax has been extended to cover the entire farming population. It is obvious that the health board collection arrangements must be reviewed in the light of the changed treatment of farmers for tax purposes.
An inter-departmental working party have been set up to review the whole situation and are expected to report shortly. While health boards will be required to collect these contributions and levies in the current year I expect that these arrangements will be changed in the near future.
I regard it as important that this House should be fully aware of the manner in which I perceive the development of acute general hospital services proceeding over the next number of years. The programme of development has been on-going since the mid 1970's and during that time the pace of implementation has had to be adjusted a number of times in the light of the prevailing economic circumstances. This has led to a ‘stop-go’ situation which has had a detrimental effect both on the service itself and on the morale of the staff involved in the delivery of these services.
 It is now clear that the current economic difficulties are the most serious we have had to face so far and it is also clear that their effects will be with us for some time. Consequently, given this situation, I have found it necessary to take a fresh look at the development programme with a view to ensuring that an orderly pace of progress can be made in the next few years. We have to accept that the level of capital resource which we can realistically expect for development will fall considerably short of that required for the existing plans as already drawn up. Therefore, it is necessary that our approach to planning in the medium term should be the application of the scarce resources which can be made available in such a manner as to ensure that a reasonable pace of development is maintained and the service in general made as effective as possible.
The dilemma for any Minister for Health is that when the capital cost of the priority demands made by the health agencies for the continuance of existing work, the replacement of refurbishing of existing structures, the building of additions to existing institutions or the building of new institutions and the replacement of equipment are added up, they come to a sum of £630 million. I have £53 million for health capital expenditure in the current year and in the period from 1983 to 1987 the previous Government aimed to provide £271 million.
The problem does not end there. New buildings attract revenue-cost increases. It was recently found that replacing the same number of acute hospital beds in a new facility cost an additional £2 million in a full year.
In these circumstances, I am convinced that the only logical approach to the major task with which we are faced is to draw up a capital development programme which can be realistically implemented in the next five years or so. The basis of such a programme must be to identify absolute priority areas of development. The criteria which must be used in such identification are:—
projects for which there are contractual commitments;  developments involving the replacement of seriously sub-standard accommodation and facilities;
developments in areas where there are no services or where services are seriously deficient; and,
developments which give rise to little increase in revenue expenditure.
The capital budget available for health in the current year is £53 million. For planning purposes, budgetary control and expenditure projections, this cannot be considered in isolation and must be taken in the context of the medium term, five-year programme of capital developments covering the period 1983-1987 inclusive. It is envisaged that a total of £271 million (at 1983 prices) will be made available to finance such a programme — that is an average capital budget of £54 million per annum.
The capital resource, therefore, available must mean that this five-year programme will fall considerably short of the expectations which have been raised throughout the country in the past few years. It is my intention that the programme will provide a mix of projects in the general hospital, geriatric, psychiatric and community-care areas.
So far as the general hospital area is concerned, plans for the development and rationalisation of the system have been agreed for some time. The resource required to implement these plans in total, is very great indeed and can only hope to be made available on a long-term basis. So in drawing up the general hospital content of the medium-term programme, the criteria I mentioned earlier have been applied. On this basis, the programme will include a number of major projects, throughout the country, which, though limited, I am convinced will provide an appropriate infrastructure on which we can advance our agreed plans to finalisation as resources become available.
Of particular concern to me at the moment, is the blatant need to bring the accommodation and facilities for geriatrics up to acceptable standards and level of provision. It is an unfortunate fact that to a large extent this area has been  neglected, by successive administrations. This situation cannot be tolerated any longer in a society which claims to pride itself in the esteem in which it holds its elderly citizens. It is regrettable that the demands made by society in general and, I am obliged to say, by the medical profession, at acute hospital level in particular, over the years for development in the health services have largely ignored the needs of this very vulnerable group. I intend in the next few years to remedy this situation in so far as I can within the constraints of the limited resources available. This will mean inevitably that some major projects in the acute general hospital programme will have to be deferred in the short term, or at least reduced in scale, if we are to be serious in demonstrating our concern for the elderly and other vulnerable groups in our society.
The psychiatric services have, without doubt, received less than a fair share of resources in the past. I intend to continue in my endeavours to rectify that situation. This year my Department will be spending in the region of £150 million on the psychiatric programme. Despite the difficult financial climate I am totally committed to providing a realistic level of Government support for our mentally ill population.
I will of course be seeking a high level of co-operation and flexibility from all involved in the direct provision of the services. I am happy to report that health boards have been especially conscious of the need to supplement in a positive fashion, the attempts by central Government to modernise and develop the services. A planned programme of improvement schemes in our district pyschiatric hospitals commenced last year. It was funded by my Department with health boards also contributing out of the resources at their disposal. Much good work was achieved and it is the Government's intention to continue to support the scheme in this and future years. This year I am making a sum of almost £2 million available. Living conditions have already improved for many patients and I am convinced that the continuation of the scheme will effect considerable further changes in the environment of long-stay  patients in particular. This development is long overdue. Whereas the number of in-patients is on the decline we still had, at the end of last year, over 13,000 psychiatric beds. Almost 60 per cent of those patients had been in hospital for five years of more. This is an appalling statistic and it very clearly demonstrates the need to continue in our efforts to provide a decent standard of living for those who are spending long periods of time in old and uncomfortable institutions.
The emphasis in the development of further services will, however, be on the provision of community facilities. With the improvements of chemotherapy and medical and psychiatric skills many people, who previously would have had to be treated as in-patients, can now live outside of the hospital environment. There has been considerable development of community-based services throughout the country, most district hospitals having been involved in establishing hostels, day hospitals, day centres and workshops to cater for discharged patients and for people presenting for the first time with psychiatric disorders. I have proposals before me for the further expansion of community facilities. While there are many difficulties I would hope that a number of the projects will be in operation by the end of this year. Health boards are being asked to give serious consideration to the concept of redirecting resources to the psychiatric services from within the totality of the health services and I am confident from my discussions with them, that they will make every effort in this regard.
In view of the continuing shift in emphasis away from institutional care and the need to set out in a clear fashion the most appropriate range of services — both community based and hospital based — which will be required in the future in each health board area my Department established an informal study group at the end of 1981 to prepare an overall planning framework for the development of the psychiatric services. Such an exercise has already been carried out with success in other areas of the  health services and I look forward to receiving the report of this group in due course.
There is one particular area which falls within the ambit of the psychiatric services programme to which I would like to make a particular, brief reference. I will come back to it later; it is the provision of treatment facilities for drug abusers and addicts. The Government have established a special committee of Ministers of State to review the drug problem urgently. Their recommendations will be available within the next few weeks. In the interim, however, I am sufficiently convinced of the magnitude of the problem in the greater Dublin area to have recently approved of the provision, by the Eastern Health Board, of community based facilities for drug abusers. I have also recently approved tenders submitted by the health board in respect of the provision of a youth development centre in the grounds of the Central Mental Hospital, Dundrum. It will provide secure accommodation for young people whose behaviour has resulted in their having difficulties with the law. Such behaviour will include drug-related offences. I shall return to this subject later in my statement when dealing with the community protection programme.
Since becoming Minister for Health I have had a number of opportunities to discuss the present state of the mental handicap services with representatives of voluntary organisations. They have impressed on me the need to maintain the existing level and high standard of our mental handicap services, and also to give due consideration to the need to provide further development in relation to providing services for sub-groups within the mental handicap population, particularly the adult mentally handicapped. The Government and myself are committed to regarding the mental handicap services as having a particular priority within the health and social services.
The Medico-Social Research Board published earlier this year preliminary findings of the census of the mentally handicapped in the Republic of Ireland, 1981. The publication of these findings allows us to compare them with the  results of the previous census of the mentally handicapped carried out by the Medico-Social Research Board in 1974. In the intervening period, a number of trends have become apparent. In line with the increase in population generally, there has been an increase in the actual number of mentally handicapped persons. This is due to an increase in the number of adult mentally handicapped and these people present a severe challenge to us to provide adequate accommodation and activation for them. The preliminary findings also show up that there seems to be an apparent drop in the number of severe and profound mentally handicapped which is a welcome finding. Another interesting result is that there has been a notable reduction in the number of mentally handicapped maintained in psychiatric hospitals which decreased from 2,744 to 2,377. This figure should be further reduced when additional residential places for adult mentally handicapped, currently in planning, come on stream.
When the complete findings of the census are available, I will be requesting my Department to examine them with a view to adjusting the projections which were contained in the 1980 Department of Health Working Party Report on Services for Mentally Handicapped.
I was pleased earlier this year to confirm the out-going Government's decision to exempt certain new priority projects in the mental handicap services from the effects of the current embargo on recruitment of staff to the public sector. This allowed 150 new jobs be allocated to the mental handicap services so that units which had been lying vacant up to a period of two years could be opened. However, I am conscious that there are a significant number of places for the mentally handicapped which cannot yet be commissioned. In addition, the new Centre for the Mentally Handicapped at Cheeverstown House, Templeogue, Co. Dublin which will provide 130 residential places and 154 day places is now nearing completion. I am considering ways and means in which these places can at least be phased in.
As I have indicated, there has been a  decrease in the number of mentally handicapped persons resident in psychiatric hospitals. In general, psychiatric hospitals are not places for the mentally handicapped whose needs are different from those who are mentally ill. However, many of our mentally handicapped already in psychiatric hospitals will probably spend a significant portion of their lifetime there. Much of the moneys allocated to the improvement scheme for psychiatric hospitals will go towards alleviating poor living conditions. However, I would hope that there would be a parallel effort to ensure that adult mentally handicapped person in psychiatric hospitals receive an appropriate level of stimulation and care rather than mere custodial care.
The contracts have now been signed for the construction of a new centre for the mentally handicapped at Swinford, County Mayo. This facility will provide much needed places for an area which has a significantly higher incidence of mental handicap that most other areas in this country. In addition, I have a number of proposals before me regarding the provision of further residential accommodation for the mentally handicapped and I intend to look at these as sympathetically as possible within the resources available to me in order to ensure that at least planning on this accommodation is progressed further.
There has been great emphasis, particularly in recent years, on the development of community and welfare services. Everybody agrees that caring for people in their own communities is far preferable to institutionalisation. But to some extent we have only being paying lip service to this ideal. While one must acknowledge the very rapid development and progress in the area of community care in the seventies it is disappointing to note that in recent years the percentage of the total health budget allocated to this programme has been decreasing. Quite frankly, successive Governments have simply not lived up to their many commitments in relation to the development of community care and personal social services and this is clearly reflected in the  budgetary allocations for these services in recent years.
The notion that our health services can only advance if every local community has a hospital, and the bigger the better is wrong. As politicians we have a very serious responsibility to educate ourselves and the public in regard to the most effective way to provide health services rather that blindly to lead local campaigns for more and more hospital accommodation without giving a thought as to whether or not there are not more beneficial and less expensive alternatives. It will be my policy as Minister for Health to reverse the present trend.
There are many valid reasons why we must concentrate on the development of our community care and personal social services. We cannot but be concerned at the escalating cost of hospital treatment and the fact that an increasing proportion of the total health resources is being swallowed up by our institutions, especially the acute hospitals. Yet when one looks closely at admissions it is evident that in every institution, be it an acute hospital or a long stay nursing unit, there are some people who should not be there.
These people could, with adequate community services, live at home and get whatever care they might require while living independent lives as integrated members of their community. A large proportion of our health expenditure, therefore, goes on what I would term “meals and accommodation” costs. If the treatment and care which is needed can be given in the out-patient department or in the home this element of health expenditure could be greatly reduced. But I am not simply looking for cheap alternatives. The further development of our community based health services will be very expensive and will not be possible without a switching of funds from the hospital programme.
In promoting more community care I am conscious of two important considerations: that in many instances treatment and care in the community can be as effective as treatment in a hospital or other institution; and that, generally speaking, it will be more acceptable to  the patient and to the patient's relatives.
Sometimes there is no difficulty in persuading patients and relatives that home care is preferable to admission to hospital. This is particularly true of illness in children. On the other hand, there may, understandably, be considerable resistence on the part of the relatives if the burden is likely to be heavy and continuous as in the care of the physically or mentally disabled elderly patient. It follows that community care, whether for children, the elderly, the disadvantaged or the handicapped, must be designed to aid the relatives as well as the patient.
I fully recognise that there are conditions for which there is no alternative but admission to hospital and that, once admitted, patients are entitled to the highest quality medical treatment and care that is available. Equally, I recognise that there are many serious deficiencies in our community services and that these cannot and will not be tackled unless we are prepared to allocate a greater proportion of our total health resources to this area than we have been doing in recent years.
With regard to the general medical service, with effect from 1 October last year nearly 900 items were withdrawn from re-imbursement under the general medical service scheme. I have had the position reviewed in relation to items for which payment continued to be made and to the items which had been excluded. This extensive review has been completed and I have been able to re-admit some preparations to the scheme. These included drugs in a number of categories among them
—analgesics for persons suffering from rheumatoid arthritis
—simple iron preparations
—tablets and capsules for the treatment of allergies.
These will meet the needs which have been widely expressed by both doctors and patients. The changes I have made represent the maximum improvement possible at present. I have continued to urge the health boards to ensure they identify and help those who, because of particular individual circumstances,  might need assistance in relation to excluded items. I was glad to hear that both the medical and pharmaceutical organisations commented favourably on the helpful approach of the health boards in this regard.
I expect to receive by September the report of a working party which is currently reviewing the operation of the general medical service. The terms of reference of the working party are such that its report should be of major significance for the development of primary care in Ireland. One of the principal issues to be addressed by the working party is the basis on which doctors should be remunerated for their services. This is a topic on which I have an open mind. I am sure that the working party will approach this sensitive issue aware of the differing considerations that must be taken into account, not least the requirement of value for money, which now more than ever must be met by all services. When I have received that report I shall be in a position to take decisions on the future development of this important service.
Earlier this year I concluded an agreement with the Federation of Irish Chemical Industries. Since the great majority of drugs used in this country are imported from the the United Kingdom the agreement set a relationship between prices here and those in the UK. The effect of this has been to reduce the prices of many medicines. The total savings which will accrue throughout the year cannot readily be estimated in advance, however, as this will be dependent, to some degree on the performance of the punt vis-á-vis the pound sterling. I am still evaluating progress in this area. For the majority of drugs and medicines the agreement provides, for the first time, a formal link between prices here and in the country of origin, and sets a limit on prices here. I believe it will be shown to be a considerable advance from my Department's viewpoint on the earlier agreement.
The Health (Family Planning) Act has been reviewed in my Department and I have received a detailed report on that review. The House will be aware that I am not satisfied with certain provisions of the legislation. I am considering these  reservations in conjunction with the report on the review to establish the extent to which the Act requires amendment. The programme for Government includes, among the items relating to health, the provision of full family planning advice and facilities in all cases where needed. I intend to submit this review to the Government in the very near future.
Last year, due to financial cut-backs, the level of dental and ophthalmic services to medical card holders was severely curtailed by health boards. In fact in most health boards the ad hoc arrangement for the provision of dental services by dentists in private practice and the scheme under which ophthalmic surgeons and ophthalmic opticians in private practice provide a sight testing service were discontinued entirely for a period of the year. For the current year the health boards have been requested to ensure that as far as possible essential dental and ophthalmic services are provided for medical card holders throughout the full year.
A general review of the public dental services is being carried out by the Departments of Health and Social Welfare with representatives of the dental profession. There are problems associated with the existing arrangements and one of the main objectives of the discussions is to identify these and see what can be done to eliminate them.
The Report of the Restrictive Practices Commission on its public inquiry into the restriction, imposed by section 45 of the Dentists Act, 1928, of the practice of dentistry, including the supply of dentures, to registered dentists has recently been published. The report recommends that the legislation be amended so as to provide that the general prohibition on the carrying on of dentistry by a non-dentist does not apply to the provision of dentures to a person of eighteen years of age or over provided it does not involve work being done on living tissue. Obviously, it will now be necessary for me to consult with the different interested parties in regard to this recommendation. Following these consultations  I will make recommendations to the Government as to what action they should take in the matter. Should the Government's decision involve a change in the legislation this could be dealt with in the context of a new Dentists Bill, preparation of which is well advanced. This Bill will replace the Act of 1928 which is obsolete in many respects. I expect to be in a position to introduce the text of the new Bill after the summer recess. I know that this long-awaited legislation will be welcomed.
One aspect of the public dental service which is often the subject of criticism is the orthodontic service. Arrangements are being made at present to appoint a number of consultant orthodontists to the health boards. These appointments should result in a quick reduction in the present waiting lists for orthodontic treatment.
I think it goes without saying that careful attention to the planning and operation of the preventive public health services makes sound economic sense. The impact of many diseases and conditions of ill-health which are prevalent in Ireland is considerable in terms of human suffering and pressure on primary health care and hospital resources. In view of this, there is a need to develop programmes aimed at the promotion and maintenance of healthy practices and the prevention of disease.
In the area of infectious diseases control, I have been concerned that the levels of acceptance for the routine childhood vaccinations against diphtheria, tetanus, whooping cough and polio have declined in recent years. As a result large numbers of children are not protected against these diseases and their distressing and often disabling consequences. In an effort to maintain acceptable levels of immunity, I have issued comprehensive guidelines to the health boards asking them to implement as fully as possible the Department's recommended programme of vaccination and immunisation.
I have also reviewed the current programme relating to the prevention of rubella — german measles — in women.
 In view of the importance of the rubella vaccination in reducing congenital malformations and the general level of physical and mental handicap, I have asked the health boards to extend the rubella prevention programmes to women of child-bearing age additional to those categories covered by the programme which were previously in operation.
Tuberculosis and sexually transmitted diseases are also causing concern at present. I recently initiated reviews of policy relating to those diseases. The objective of the reviews is to evaluate the true incidence of the diseases in question and ultimately to devise revised programmes aimed at their prevention and control. About 2,000 new cases of sexually transmitted diseases are notified to my Department each year, the vast majority of which have been brought to our attention through hospital clinics. For a variety of reasons, including the intimate nature of sexually transmitted diseases and a reluctance on the part of doctors to report them many cases are never notified. It is extremely difficult, therefore to determine the true incidence of sexually transmitted diseases.
I do accept that the incidence of sexually transmitted diseases is high in this country and it is apparent that steps have to be taken to develop a cohesive programme aimed at prevention and control. Towards developing such a programme, I have initiated a review of my Department's control measures. An integral component of a central programme for sexually transmitted diseases is the dissemination of information aimed at increasing an awareness amongst the public of the dangers of contracting such diseases and the means and facilities available for their treatment. Prevention and control through public education will, therefore, be an important feature of the revised programme.
A sexually transmissible disease causing widespread concern is Acquired Immune Deficiency Syndrome — or AIDS as it is commonly called — and the indications from other countries are that it is fast becoming an extremely serious public health problem. On the basis of the information available regarding  AIDS, the syndrome is thought to involve a breaking down of the body's immune system thus rendering the sufferer prone to serious conditions of ill-health, such as cancer or even death. Mortality rates as high as 40 per cent have been reported from some countries.
Initially, AIDS appeared to be confined to male homosexuals but gradually it became clear that persons other than male homosexuals were also susceptible to the syndrome. Those included intravenous drug-users, immigrants from Haiti, haemophiliacs — as a result of treatment with contaminated blood products — women — through infected sexual partners — infants — possibly by perinatal transmission — and children — possibly as a result of exposure in a high risk household.
The cause of AIDS and the mode of transmission are unclear. Initially, it was thought that there was something in the lifestyle of male homosexuals which predisposed them to the syndrome. However, when persons other than male homosexuals began to develop AIDS, the possibility of a transmissable agent, possibly a virus, being involved was seriously considered. The most up-to-date information from the World Health Organisation about AIDS is that multiple factors, rather than a single novel virus, possibly induce the syndrome.
My Department have asked each director of community care and medical officer of health to investigate whether any cases of AIDS have occurred in his community care area and where cases have occurred to give detailed information regarding such cases. To date, two cases of AIDS have been reported in this country. One of the persons subsequently died. My Department will continue to liaise on a regular basis with the directors of community care and medical officers of health to ensure that up-to-date information about the occurrence of AIDS is available so that appropriate measures may be taken to protect the public health.
At international level, my Department are in constant touch with WHO to ensure that information about the syndrome, its possible causes and modes of  transmission is routinely available. The availability of such data will complement our national information and is vitally important to my Department to enable it to implement interventions to protect the public health.
It has been established that our food supply and our food consumption patterns are closely linked with our health status. For example, we have high morbidity and mortality rates associated with heart disease, strokes and certain cancers. Many cases of these diseases are preventable and require little adjustment in lifestyle. At my request, the Health Education Bureau are conducting public education programmes on nutrition. These programmes will be developed in the long-term to include nutrition education programmes aimed at health professionals, teachers and school children. I am also examining other elements of a food and nutrition policy for this country in consultation with other appropriate organisations with a view to developing a co-ordinated approach to the planning, implementation, monitoring and evaluation of such a policy.
One prominent feature of Irish life which merits particular attention and which does not involve any financial outlay is the general casualness in relation to matters of hygiene. The primary purpose of the national hygiene campaign which was launched in 1977 was to improve the living environment of the Irish people to make our country a better and healthier place to live in. It was the hope that this campaign would inaugurate a permanent change in the style of Irish life.
These were ambitious targets. It is generally acknowledged that the campaign did raise the level of public awareness of the need for food and personal hygiene but it must be conceded that our standards are generally less than would be tolerated elsewhere, particularly with our Continental neighbours. This reflects very badly on us as a nation. It affects our health and we have to suffer deserved criticism from visitors with such consequences for our tourist industry as that may entail.
If we are serious about national hygiene it will require a determined  effort. My Department have initiated consultations with the agencies concerned to see what can be done to increase public awareness to the need for hygiene. In the course of these discussions it is hoped to identify target areas and the groups to whom efforts to raise hygiene standards should especially be directed.
Drug-related offences have, in the past two years, become a major problem. They are liable, in particular, to arise from the addiction of individuals to heroin. This addiction has been growing and is now a major problem in Dublin and its incidence in the inner city area has recently been shown to be of the order of 10 per cent among those aged 15 to 24. It can cost an addict about £100 a day for his supply of heroin and money is found, in the majority of cases, by recourse to crime. The action which should be taken in relation to those who are currently addicted and the steps necessary to prevent further increase in the numbers abusing this drug are being given priority consideration by the special Governmental Task Force on Drug Abuse. While most concern is currently being expressed about heroin there is also evidence of the abuse of other hard drugs such as cocaine. Cannabis usage is also widespread and it is the drug most widely abused at present.
I am convinced that there is a major problem to be dealt with and, as I have said, we are taking action to deal with it. In doing so it is important to keep our problem in perspective and to remember that all our European neighbours are having to cope with drug abuse problems, which in many cases are more serious than ours. There is, throughout Europe, and in other continents, a general problem of substance abuse which all countries are striving to contain.
Alcoholism has now assumed the proportions of being at once a major health and a major social problem for our country. Alcoholism is now the most frequent primary diagnosis for admissions to our psychiatric hospitals. There were over 7,000 such admissions in 1980 and we know there are at least 45,000 alcoholics  in the country. Also, there are almost 600 deaths and 9,500 serious injuries each year due to road traffic accidents. A high proportion of these accidents are caused by over-indulgence in alcohol.
The Health Education Bureau have recently completed the design of a special alcohol education programme for second level schools. The aim of this programme is to develop a responsible attitude in young people to the use of alcohol. The programme will be made available to schools in September 1983.
Young people will be provided with educational experiences and exercises to enable them to develop healthy, mature attitudes towards the use of alcohol. The programme is attractive in that it lays emphasis on examining self-esteem and relationships while, at the same time, presenting factual information. The bureau will also be launching a teacher training programme at 15 centres around the country to facilitate the entry of the alcohol programme into schools.
The bureau have produced a set of alcohol fact sheets which explore various facets of alcohol and alcoholism. These are available on request to educators and others dealing with alcohol abuse. The bureau have also produced a pamphlet on alcohol abuse for distribution to the general public.
For those for whom health education is too late, effective treatment services must be provided. Our psychiatric services are broadening their scope to include specialised treatment programmes and I will be keeping them under close review. I will be encouraging the expansion of community-based services in this as well as other areas of psychiatry. A significant development in recent years has been the introduction of specialised counsellors dealing with alcoholism. They are playing a crucial role in helping not only problem drinkers but the family and friends who are suffering also because of the addiction. I will be giving careful consideration to increasing significantly the number of counsellors in the coming year.
Tobacco smoking is now recognised as the largest single preventable cause of premature death and disability in our  society. Two decades of continuous research overwhelmingly ratify the original scientific indictment of smoking as a contribution to disease and premature death. In Ireland we are in the unenviable position of having the heaviest smokers in the EEC and our smokers have been substantially increasing their consumption in recent years. The notable increase in smoking among women and young people is particularly worrying.
I have been reviewing the position generally and I am satisfied that urgent and more stringent measures will need to be taken if we are to combat this smoking epidemic. I am thinking specifically of action in such areas as, health warnings, smoking in public places, health education and the strengthening and enforcement of the tobacco legislation. These measures will indicate clearly the Government's resolve to tackle the serious damage being done to the nation's health through smoking.
In the period 1974 to 1981, the number of staff employed in the health services increased by 46 per cent. This, in effect, meant that total numbers employed overall went up from less than 40,000 to about 58,000, an increase of more than 18,000 staff. This increase was not uniform among the different categories of staff employed. The biggest increase was in areas where skills had perviously been in scarce supply such as para-medical grades which went up as much as 91 per cent. Medical and dental staff went up by 67 per cent. The supply of nurses went up by 35 per cent, clerical and administrative staff by 72 per cent and catering and domestic staff by 58 per cent. This period of continuing growth was brought to an end in July 1981 when the Government effectively embargoed any further increase in the number of posts in the public services. Subsequently, the Government devised further measures designed to reduce numbers progressively as vacancies arose.
The underlying purpose of the policy adopted is to improve administrative efficiency and to bring public expenditure into line with our resources. Essentially, therefore, we are looking for cost containment while maintining and, if possible,  improving the level of services. Unfortunately, the containment strategy forced on us by present circumstances includes not only curtailment of funds, but a reduction in levels of employment at a time when alternative employment opportunities are scarece. When the strategy was formulated, it was expected that target reductions could be achieved by leaving unfilled a proportion of the vacancies which arise through natural wastage. It now appears that the rate of turnover has significantly decreased, making it more difficult to achieve targets within the time scale set down. This strategy will, therefore, need to be reviewed and consideration given to alternative approaches.
I intend to make a definitive statement shortly on the many recommendations and views contained in the report of the Working Party on General Nursing. These recommendations and views range over a whole spectrum of nursing matters, such as the role and education of nurses, administrative structures and the control and disciplining of the profession. The working party was widely representative of the nursing profession and contains the considered views and recommendations of highly qualified and experienced persons involved in the nursing area. In addition, we have now received the observations, and comments of the various interested nursing bodies and organisations — too numerous to mention here — and for which I am very grateful.
New nursing legislation is now being prepared in my Department. It will replace the existing Midwives Act and the Nurses Acts and it will provide for the restructuring of An Bord Altranais along the lines recommended in the report of the working party. The new board will be more representative of the various branches of nursing and will be able to exercise greater control over the profession and its future development, as indeed has been sought by the profession itself. I would hope to be in a position to put the draft legislation before the Oireachtas before the end of the current year.
The working party have recommended  that a central application bureau should be set up to deal with applications for entry to nurse training schools and it is intended that the new Nursing Bill will contain a provision giving An Bord Altranais statutory powers to enable them to set up a central applications arrangement. In the meantime, the board are carrying out a feasibility study with a view to introducing an arrangement on a voluntary basis. I know that such a development will meet with almost universal approval.
Investment in reseach may not yield immediate results and because of this there is always the danger of it losing out to the pressing needs of hospital and community services. Yet the fruits of research whether of an evaluative, epidemiological or clinical nature, can chart the course of an effective and modern health service.
For these reasons and notwithstanding the pressures from other sectors of the health service a total of just over £2 million has been allocated between the two reseach agencies under the aegis of my Department. These agencies are the Medico-Social Research Board and the Medical Research Council. It is a fact that the potential number of researchable topics by either body is indeed very large. Therefore, an attempt has to be made to select researchable items on the basis of their relevance to Ireland and also their urgency. A major consideration must also be research work done in other counties and in this regard contacts established through the machinery of the European Community can prove very valuable.
The Medico-Social Research Board carry out a wide range of epidemiological reseach. This includes studies of the activiety and morbidity patterns in general and psychiatric hospitals and also in homes for the mentally handicapped. The board also engage in reseach in the area of mother and infant health much of which is aimed at the prevention and detection of disease and handicap. Another area of immediate relevance which the board investigate relates to the incidence of drug abuse especially in urban areas.
 The Medical Reseach Council, on the other hand, are concerned with basic clinical research. They, too, within the limits of their budget, try to tackle those conditions which either because of their origin or incidence have a special relevance to this country. They have recently concluded special work on brucellosis and are continuing their investigation on alcoholism, coeliac disease, hypertension, lung fibrosis and hospital infections. The council also promote medical reseach in our hospitals by giving research grants to medical personnel with appropriate research projects.
I have been considering the whole question of private health care and, in particular, the provision of State funds to subsidise this care. In this connection, I have already discontinued the subventions which were formerly payable by health boards for patients in private general hospitals. I am also looking into the question of the use by consultants of public hospital facilities in the treatment of their private pateints.
I have also decided that the development of a private hospital in association with a public hospital will not in future be facilitated by me by, for example, providing a site for its construction. I am examining the possibility of my taking the legislative powers necessary to control the provision of such private hospitals.
Finally, regarding a discussion paper or White Paper on health services I have already stated that it is my intention to publish before the end of the year a discussion document on the health services and their future development. I have not, therefore, gone into great detail today on all facets of the health services. This will be done in the discussion document and will provide an opportunity for all involved in or concerned about our health services to put forward suggestions for changes and improvements. In moving this Estimate I was, therefore, somewhat selective in the choice of topics on which I have commented this morning.
Dr. O'Hanlon Dr. O'Hanlon
Dr. O'Hanlon: The Minister has given us a very comprehensive statement on the health services and I suppose in many  ways it is more interesting for what was not in it than for what was in it. We are all agreed that there must be a shift in emphasis from hospital care to community care and a shift to prevention. The World Health Organisation in their publication Health Services For All by the Year 2000 have made very clear the point that the emphasis in the future, as the Minister stated in his address, should be on prevention, on health as a way of life, on the prevention of ill-health and on community care for all.
We must all be concerned about the high cost of health services and the cost of non-capital services going up from £328 million in 1977 to over £1,000 million in the current year. It is mainly inpatient hospital services that account for this very large amount. However, while we can all subscribe to the view expressed by the Minister, one of our main concerns must be to ensure that we provide a proper service in this country at present. for example, the Eastern Health Board area particularly is one of very rapid growth and there are problems in that facilities are not being provided for people in the new areas. I would like to hear the Minister speak about this here today. We would like to know what facilities will be provided and what the Government intend to do to ensure that there will be health facilities for people in the new growth areas. We have the highest birth rate in the EEC countries and a massive expansion, particularly in the Eastern Health Board area.
As I said, the acute hospitals account for the largest proportion of the health budget and the rate of increase in admissions to these hospitals should be a matter of concern. In 1960 about 250,000 people were admitted to these hospitals; in 1980 the number was 540,000 and in 1981 it was 560,000. I would like to hear the Minister say something about new developments in the out-patient departments in the acute hospitals, because it is recognised that a great deal more work could be done in the out-patient departments of hospitals and so save admissions to these very expensive beds. We have a high percentage of beds compared with  other countries in Europe. There should be at this stage an official policy on the development of out-patient services with emphasis on the needs of patients. Much of the work, investigation and many of the tests that are carried out in hospital beds could just as easily be done on an out-patient basis. In the development of new and existing hospitals, I would have thought that the Minister might have said something about what the official policy is on the development of day care facilities in order to cut down costs.
The Voluntary Health Insurance Board have a built-in bias towards inpatient hospital facilities. This is something that should be looked at, because if they were to provide cover for out-patient facilities this might help to cut down the very large number of admissions, which is escalating at a very rapid rate. The pattern of illness has changed over the years from acute to more chronic illnesses and this brings its own problems. I have never been over-enthusiastic about the way the staff embargo has been implemented. It was introduced by the last Coalition Government in July 1981 and does not take account of the essential needs in particular areas of the services. Many institutions are closed for two years because they have not got the staff to man them. I do not think it is good economic sense to put up a building and then to leave it idle and have it deteriorating without making some effort to provide staff.
The health boards were obliged to reduce their staffs by 2 per cent before the end of March this year. It would be more appropriate if the health boards were given their allocation for staff and let them decide how they could make best use of it. If the Minister's instruction was implemented it would mean a reduction of 600 staff in the health services at a time when there are no alternative jobs for people trained in this field. The health boards, with knowledge of their own staffs and with co-operation, might, with the funds available, be able to keep most of the staff or at least not have to reduce it by 2 per cent. They might also be able to man the buildings around the country  that are closed because they have no staff.
On the capital expenditure side the Government are spending £53 million this year, £2 million less than in the original Estimate of the outgoing Government. When the Minister calculated the amount of money he would need if he were to provide all the capital projects that are listed as priorities, he came up with a figure of £630 million. It is surprising, therefore, that the Government in their wisdom, or lack of it, decided to reduce the capital allocation by £2 million. Over the last few weeks we have had a number of questions relating to various projects that are in urgent need of funding. This £2 million would have gone a long way towards helping with those priorities.
There has been great development in the building of acute hospitals, started by our party in 1977. These hospitals are in strategic places and are very necessary. Perhaps when the Minister is replying he could say what the position is on the building of the new hospital in Cavan and if they have been notified yet that they can go to tender for that project.
The Minister stated that the Government have a commitment to the psychiatric services and to services for the mentally handicapped. There have been very good developments in the psychiatric services on the capital side over the years. But there is still need for much more development and there are priorities there which should be attended to. I do not think it is sufficient to say that the money is not available and that these things will not be done because, as the Minister pointed out, many people who are in psychiatric hospitals have been there for more than five years and it is essential that we make some commitment to provide proper facilities for these people.
This day week I visited St. Brendan's and the community services centre on the north side of the city provided by St. Brendan's and I was very pleased with what I saw. There were defects in some of the buildings but the level of activity and the work that was carried on there is  something of which we can be justly proud. The admission unit to St. Brendan's was newly set up a few years ago and it has resulted in the fact that there are less admissions now in the Eastern Health Board area. They have reduced admissions to the psychiatric hospitals, in contrast with the other health boards, by virtue of having a strict regime for the admission of patients.
The community service side needs to be developed further, although they have been doing excellent work. Again, the main difficulty is on the capital side: they do not have proper facilities. For example, Ballymun Health Centre needs more and more space for community welfare officers and the distribution of supplementary allowances. The Minister should ensure that proper facilities are provided so that community services will be developed.
I should like to ask the Minister to look at the very serious, indeed unique, situation that exists in two hospitals in Dundalk and Bantry where the county physician is asked to also be the county obstetrician. When the county surgeon retired in Dundalk, the new county surgeon's terms of reference did not say that he must be an obstetrician or a gynaecologist. We cannot allow a situation to continue where a man who is not qualified to carry out surgery is expected to take the responsibility of being the county obstetrician with no surgical backup. I am glad to say that the Chief Executive Officer of the Eastern Health Board recognised his responsibility to the patients in that area by going ahead and advertising for a locum obstetrician. One would have to back him in this matter.
With regard to the general medical services side, I was disappointed that the Minister did not give some opinion on remarks quoted recently in the papers by A. Dale Tussing, an American economist, who apparently has come over here to do some work for NESC. An article by him was published in the current issue of The Economic and Social Review, Volume 14, No. 3, April 1983, pages 225-247, in relation to an investigation into the method of payment of general practioners in the general medical services.
 In the summary he makes this comment:
These results suggest that some demand for GP services is induced by the GPs themselves, for self-interested economic reasons. Similar studies have produced similar results in other countries with fee-for-service methods of remunerating physicians.
I must take issue with the writer on that. Certainly, there is a small number of abuses. Machinery is available to deal with these and they are being dealt with. The vast majority of family doctors operating the family medical services are influenced by job satisfaction. The general medical services were introduced in 1972 and were a significant development in medical services at primary care level. They did away with the old dispensary services where patients did not have the right to attend a doctor of their choice.
As we have heard this morning, the cost of the health service is over £1,000 million and the cost of paying the doctors to run this service is £20 million — just 2 per cent of the total budget. For that £20 million they provide a 24-hour service, seven days a week, 52 weeks of the year. That covers 1.3 million patients — a third of the population. How anybody can say that that is not good value for money is very difficult to understand. I am speaking in my capacity as a doctor, but every other politician must agree. I would like the Minister to comment on that report. It is a reflection on the doctors who are giving an excellent service and very good value for money.
On the question of fee-per-service versus salary, there is evidence that a fee-for-service produces a better level of medical care and this is what we all should be concerned about: that the level of medical care which we provide for the people for whom we have responsibility is as it should be.
Reference has been made to comparisons with other countries — for example, the United Kingdom. There they have salaried service. There are major differences in the public service provided here at general practitioner level and in the United Kingdom. There they cover the whole population, but here only those at  high risk are covered — mainly the elderly, low income groups and large families.
The ratio of visits to doctors is the same for the high risk categories in the United Kingdom and here, but because the UK system covers their whole population there is a lower ratio. It includes those at very low risk. If one were to compare the cost of the services per doctor in the UK and here, it averages at £42,500 per doctor in the UK and £15,200 in the Republic.
There have been very few complaints from those who use the services. They seem happy with it. Indeed, not alone in relation to our health services but to our many other services one would wonder why it is necessary to import economists to chart the way forward. Surely at this stage we have enough ability to do that?
Speaking about eligibility, the Minister mentioned category one as consisting of persons with full eligibility.
Persons in this category are entitled to a full range of health services without charge and they are issued with medical cards for presentation when services are needed.
That used to be correct, but is correct no longer. Nowhere else in this Government's programme have they done a U-turn with greater vengeance than in relation to the provision of drugs for those who are general medical services cardholders. Part of their programme was to review the 900 items which had been removed from the medical services prescribed list and to ensure that necessary drugs would be restored to that list. What did the Minister do? It is interesting that he made no reference in his address this morning to the fact that he had removed the items from the list. He did tell us that he had been able to re-admit some preparations to the scheme. These included drugs in a number of categories and he mentioned some painkillers, tablets for treatment of allergy and simple iron preparations. He said that these will meet needs which have been widely expressed by both doctors and patients and that the changes which he had made represented  the maximum improvement possible at present.
The Minister has removed 274 items from the prescribed list since he came into office. I accept that some were deleted because they were no longer used, but 115 are available and many of these are used. The Minister's predecessor, Deputy Woods, left some very useful and important medicines on the list — for example, white stomach mixtures and some common cough bottles. These are very necessary for persons suffering from the relevant conditions but the Government have removed all of these preparations from the list. They have now left without these preparations those who are unable to provide them from their own resources. It is all very well to say that provision has been made and that the Minister will continue to urge the health boards to ensure that they identify and help those who because of individual circumstances might need assistance in relation to excluded items. He also said that he was glad to hear that both the medical and pharmaceutical organisations commented favourably on the helpful approach of the health boards in this regard. That is not correct. If one understands the working of the system one will know that it is not correct that the health boards are providing the necessary medicines for these people. It is all right if one is on long-term medicine and can afford to wait for three to four months until the case is processed. There is no facility whatsoever whereby the health boards are able to deal with a situation where a medical cardholder needs medicine urgently and is not getting it. We must face the reality that there is no such facility.
The length of time which the process takes is mainly due to overwork. Again, one must come back to the subject of supplementary allowances. Community welfare officers must spend an inordinate amount of time on administering these allowances. That is because of rising unemployment which results from Government policy. This means that these welfare officers are not in a position to process all the genuine medical claims  which come before them, both in terms of medical cards and of supplying these essential medicines.
Last week I asked a question about the number of people in each health board area who were benefiting from the scheme whereby the health board provide the drugs excluded from the GMS for medical cardholders. I could not get that information.
I understand that £1¼ million was saved in the first month and that the Government hope to save £8 million. When the original 900 items were removed some essential medicines were left but all the items removed were ones which could be bought over the counter. That was recommended in the Trident Report. This Government have removed medicines which are available on prescription only. When one looks at their policy document and sees statements made by the Taoiseach and various Ministers including Deputies E. Collins, O'Keeffe, Bermingham and E. Desmond, during the vote of confidence in the Government last November, one would realise that this is the greatest U-turn the Government have done since they came to office.
The medical card is being used as a method of assessment of poverty. If one has a medical card one is entitled to many benefits apart from the health service. Examples include exemption from the 1 per cent levy and the school transport charges. This creates very serious anomalies. The Minister should examine this urgently particularly in relation to the school bus charge. This is a matter which has caused difficulty for people. The charges are discriminatory. While school transport charges are not relevant to the health estimate the use of the medical card for this purpose is relevant. There are many people who will keep their children from school because they cannot afford to pay £150 for transport.
A married man with two children earning £90 per week is entitled to a medical card. He would not have to pay school transport charges and would pay about £4.90 per week PRSI. If his income increased to £100 per week he would lose the medical card. He would not be exempted from the school transport  charges and his PRSI would be £8.50. He would also have to pay £4.60 income tax. Out of a gross income of £100 per week he would take home £86.90 and would have these additional costs. If he remained on £90 per week he would take home £85.10 but would not have to pay for those services. That kind of situation has arisen because the medical card has been used for a variety of purposes other than entitlement to health care services. The Minister should look at that aspect.
As regards medicine the emphasis must be on prevention in the future. The greatest single need over the next 25 years will be to give prevention the degree of scientific and educational attention as was given to treatment in the last 25 years. The World Health Organisation recognised that. They pointed out that health investment in the past 30 years was devoted to dealing with health problems which presented themselves rather than trying to prevent those problems. They also pointed out strategies to achieve special goals by the year 2000.
There have been changes in health over the years. Many infectious diseases have been practically wiped out. The Minister spoke about some problems associated with disease particularly as a result of the fall off in immunisation. One would have to support the Minister, the Department and the health boards in their campaign to ensure that parents immunise their children against debilitating infections. The vaccine for whooping cough has been the subject of controversy in recent years. The best medical advice available states that parents should have their children immunised against it because the risk of whooping cough in small infants far outweighs the disadvantages of immunisation. One would have to support any programme to ensure the maximum number of people particularly children are immunised against illness.
There are numerous opportunities for prevention apart from immunisation. While socio-economic improvements do not concern us in health, nevertheless a Government are responsible for improved housing and adequate income. Modification of personal habits is something that needs to be stressed. The  Health Education Bureau are working on this aspect and they are deserving of the full support of the Minister. They point out the dangers of smoking in terms of heart and lung disease and the advantage of proper diet and nutrition. In the Eastern Health Board area and some community care areas there are facilities where people can go along and listen to talks on good health, for example, nutrition of infants, child care, family relationships. family planning services, personal behaviour, diet, exercise, use and abuse of alcohol which is a major problem in our society, the control of infection through immunisation and hygiene.
The health service has a limited input as regards control of pollution. This is something the Government should take seriously. The elderly and children are particularly prone to accidents. Perhaps as legislators we do not give enough attention to the prevention of accidents, particularly road accidents and the disastrous consequences they have for the people involved both in terms of mortality and morbidity and the economics of road accidents. We often hear complaints about waiting lists for hip replacements in orthopaedic hospitals. In such hospitals 40 per cent of the beds are occupied by road accident victims. Perhaps as legislators we should look at what we can do to prevent not alone road accidents but industrial accidents and so on. We should be directing our attention also to the areas of population screening, to anti-natal and to post-natal care so that we might identify defects at an early stage and deal with them. These are some of the ways in which we can prevent illness.
The elderly are a special category and their numbers are increasing. In 1979 there were in our society 361,400 persons over the age of 65 and the projection is that that figure will increase to 389,000 by 1991. Our prime concern must be to keep as many of these people as possible in the community in their own areas. This involves further development of the community care services though there has been a rapid expansion of these services in the last number of years. Excellent work is being done both by the statutory  bodies and by the voluntary organisations. Social services councils and various other groups who are involved in carrying out this excellent work for the elderly should be supported.
The Minister has told us that the percentage of money going into the community was decreasing. The reason for that is that it is always easier for a health board to cut back on community care services and on allocations to voluntary bodies. In some cases the level of assistance given to such groups in not kept in line with inflation. For this reason the community services suffer at a time of recession. The Minister should ensure that all those groups, from the health boards down, are supported properly. For humane reasons as well as for reasons of health and economics, we should make every effort to keep as many of our elderly as possible within their own areas. To that end also we should support families who wish to look after their elderly, not necessarily to support them financially but to provide facilities for them. Though such schemes as the disabled persons reconstruction grant is not a matter for the Minister for Health, the Government should ensure that they are administered in a way that will facilitate families who wish to keep their aged with them. There are many families who would be delighted to have their elderly parents with them if they had the necessary accommodation. This is an area that the Government should look at. They should ensure that local authorities take their responsibilities seriously in this matter. There is no point in saying that a certain scheme is available if, by the time it is processed, the old person whom it was intended to help has passed away. Some movement is required in respect of these schemes.
The Minister spoke about the misuse of drugs. The abuse of alcohol, perhaps, is the greatest problem facing us but we must accept that we have also a very serious drug problem particularly in the bigger towns and in Dublin. There have been some frightening official reports published in recent times pointing out how serious the drug problem is especially  in relation to the abuse of heroin. The Minister must ensure first that we try to prevent the problem from spreading and, secondly, must ensure that adequate treatment centres are provided. The facilities in this area are not adequate at the moment. We do not have an adequate treatment centre for hepatitis. a liver infection which is on the increase as a result of heroin abuse. The drug centre in Jervis Street is too small and should be enlarged. There are no facilities for the rehabilitation of the younger age groups, those under 17. One can only hope that the Minister will move rapidly in these areas instead of waiting for further reports from further committees. If there is one area in respect of which we might condemn ourselves, it is the area of setting up so many committees down through the years for the purposes of considering many different aspects of life especially those aspects in respect of which the facts are staring us in the face so that there should be no need for the setting up of any committee to tell us what the situation is and what needs to be done.
I commend the Minister for his action in removing the facilities from one doctor in relation to the prescription of dangerous drugs. The Minister is absolutely right to ensure that members of the medical profession do not abuse their responsible position by dispensing such drugs to persons who are addicted.
Last year the then Minister, Deputy Woods, allocated an extra £250,000 to the Health Education Bureau but I note that in the Estimate for this year their allocation is reduced by £250,000. This is disappointing having regard to the whole trend through the Minister's address in terms of prevention and the part that the bureau would have to play in that. I would have expected their estimate to have been increased rather than reduced. In terms of the total health budget the reduction is on a not-so-large sum — £1,500,000 — leaving their allocation for this year at £1,250,000. Obviously, in the area of drug abuse education is a very important, if not the most important element, in preventing a further deterioration in the situation. We have talked  about rehabilitation. While legal remedies are not a matter that is proper for discussion under the health Estimate, we can express concern at the small sentences being imposed on people found guilty of pushing heroin.
I was glad to hear the Minister say recently that he would be including in the Children Bill a provision to deal with glue sniffing. In its own way this habit causes problems. One hopes that that Bill will be before the House very soon. The Children Act, 1908, prohibits the sale of cigarettes and alcohol to children. One would hope that the new Bill would deal with many other substances which are a danger to young children.
This morning the Minister told us that he intends bringing a nurses Bill before the House by the end of the year. This, too, is to be welcomed but perhaps when he is replying he will tell us whether he has plans to legislate for the registration of certain other health and social professions such as social workers.
The Minister spoke also about the dental services. This is another area in which there are serious problems which must be faced up to. There is a wide variation throughout the country in the ratio of the number of dentists to the number of people they are serving. In some areas the ratio is 1 to 7,000 whereas the national average is 1 to 3,000. If a health board are not in a position to provide a dental service, particularly in the case of children and especially if they are not in a position to provide an adequate teeth-filling service for children, they should be in a position to tell the parents of these children that they can have the treatment carried out elsewhere. It is very wrong that a child's name should be put on a waiting list for the filling of a tooth and that by the time the child is called for treatment, the tooth had decayed so much that it must be removed. The inability to provide an adequate service in this area is not always the fault of a health board. They may be in a position of not being able to attract dentists to the public service. This is an aspect that the Minister should direct his attention to.
While I certainly favour an extension of the dental services to include the 12 to  16 year olds, and the wives of those on pay-related social insurance and women who work in their own homes, nevertheless, the first thing we have got to do is to ensure that the people who are presently entitled to a dental service get it. There is also a very good case to be made why the dental service, as operated by the Department of Social Welfare, should be transferred to the Department of Health. Dentistry and optical treatment are health services rather than social welfare services. I ask the Minister to look at that. He said he would be bringing in a new Dental Services Bill which would deal with the recent report from the Restrictive Practices Commission on dental prosthesis.
It is encouraging, in relation to the psychiatric services, that the number of long-staying patients is dropping while the number of admissions is increasing in each of the health board areas except the Eastern Health Board area. A special allocation of capital was given by the Minister's predecessor in 1982 to improve the buildings. Has the Minister given any special allocation this year? Does he intend to implement the Health (Mental Services) Act, 1981? If he intends to implement this Act when will he do so? When will the study group set up in 1981 start?
The Minister, referring to mental handicap, stated that 150 new jobs had been allowed despite the July 1981 embargo. Where did those posts go to? Did they go into existing services or were they used to open hostels and various institutions that were built and were left lying idle as a result of that embargo? There has been a great improvement in the facilities provided for the mentally handicapped, particularly since the commision reported in 1965. We can be very proud of the fact that our services compare favourably with services anywhere else in Europe.
There are 12,500 moderately and severely mentally handicapped people in the State and a quarter of those are in psychiatric hospitals. There has been a welcome development in recent years to segregate the people who are mentally handicapped into their own units and  provide the necessary facilities for them. We have also had the situation where, when new places are created outside for the mentally handicapped, patients are taken from the psychiatric hospitals and offered those new places. The result is that very deserving cases in the community cannot get into residential care. There should be no doubt about the priority in this case. If there is a deserving case in the community waiting ten or 12 years to get into residential care and places are provided, that person who has been waiting so long should be offered one of those places. They should not be used to thin out the existing population, however deserving they may be, or to move people from psychiatric hospitals.
Twenty six new beds have been provided in Stranorlar and 15 are being offered to patients who are at St. Conal's Hospital in Letterkenny when there is a waiting list in the community. The least I ask the Minister to do is to ensure that the health boards will draw up a priority list of who should get those beds, let them be from existing residential care institutions or from the community. People in the community, who have very high priority because of how difficult it is to look after themselves in the community and how difficult it is for those looking after them, should get preference. The Minister spoke about Swinford this morning. What is the modern thinking on residential care units as large as Swinford which has 200 beds? Is there any changed view in relation to that?
We should aim to keep all the mentally handicapped and the physically handicapped in the community rather than in residential care. While some people would close down all residential care units one must accept that there is need for them and there are a number of mentally handicapped people who are not able to look after themselves or their parents are not able to look after them in the community. The aim should be full integration into the community in accordance with the capability of those people in terms of family life, school and work. It was interesting recently to hear the  prior of St. Mary's, Drumcar, Brother Thomas, state, in relation to work, that for some reason we have moved away in our psychiatric hospitals and our residential units for mentally handicapped people from agriculture as a means of work. In a country where we are importing so much now in terms of horticulture and agriculture, the Minister should encourage the institutions for which he has responsibility to see that the land is made use of for agricultural and horticultural purposes as a means of occupational therapy for these people.
I welcome the introduction of the Children Bill. I hope it will be comprehensive and deal with the social services, juvenile justice and the abuse of substances, which the Minister said it would deal with. Has the Minister any plans to bring in regulations to govern the standards in day nurseries and also to regulate the training of people who work in those nurseries? He did not talk about the National Community Development Agency set up by his predecessor. It is unfortunate that that agency were not given an opportunity to work and that the Minister disbanded them after he came into office. They had wide-ranging powers to support community development, self-help and community activity. They would have worked to eliminate poverty and deprivation. In view of the fact that the Minister has not so far provided any alternative, it is a pity they did not have an opportunity to show what they were capable of doing this year.
The European Social Fund is under review at the moment. We have provided some very fine facilities for the handicapped through that fund. I would ask the Minister to ensure that in the review we will not be any worse off vis-á-vis the allocation we get from the fund. We have been getting a very high percentage compared with other countries. This is a recognition of the excellent work being done in terms of community workshops, sheltered workshops and so on for the handicapped generally.
The Minister said he was reviewing family planning legislation. I do not know what the cost of the comprehensive service he may offer will be but there  certainly does not seem to be any great public demand for a change at the moment. However, we will wait and see what legislation is introduced.
Towards the end of his statement this morning the Minister said: “I am also looking at the question of the use by consultants of public hospital facilities in the treatment of their private patients.” This facility is traditional in our hospitals. In fact it is built into the conditions of service. I have never heard of its causing any particular problem and, before the Minister makes any rash decision, I would ask him to consult with the professional organisations, the health boards and the trade unions in particular because this year for the first time there has been a differential in the amount at which a contribution has to be paid, namely, £13,000, and the eligibility for service, namely, £11,000. It is people above that £11,000 who will suffer if the Minister makes any dramatic change. I impress on him that he should consult with the unions about this.
He went on to say: “I have also decided that the development of a private hospital in association with a public hospital will not in future be facilitated by me, like for example, providing a site for its construction.” I do not understand the rationale behind that. Our first concern must be to provide a proper medical service for all who need it. Consultants are entitled by their contract — they are, in fact, actually obliged because the whole population is not covered by a comprehensive free medical service — to achieve the ideal of having their workplace knitted into the one location to obviate the need for travelling to a private hospital on one side of the city and a public hospital on the other side. Surely the ideal is to have the workplace on one site, and it amazes me that the Minister would even suggest he would not have a private hospital on the same site as a public hospital.
With regard to insurance, most people over £11,000 are obliged to insure with the VHI. They are obliged to avail of private facilities and, since the State is not providing facilities for all, it is in the interests of the State to ensure that proper private facilities are provided for  those who must avail of them. They have no choice. I repeat, the Minister should consult with the professional organisations, with the trade unions and the various other interested bodies before introducing what one might term a real touch of socialism into our medical services. This was tried without success in the UK by the Labour Party. If I were the Minister I would certainly have another think about it.
Another change the Minister has introduced is a change in Comhairle na nOispidéal. That body is obliged by law to regulate the consultant services. The Minister has now decided that before they do that they must have each post cleared in the Department of Health. In effect, the Minister is taking the responsibility unto himself. I should have thought the more practical approach would have been to sit down and talk to An Chomhairle and work out a policy whereby An Chomhairle would still be allowed to carry out their statutory function having regard to the problems the Minister has outlined. What he has done in effect is taken power unto himself to decide where counsultants should go and where they should not go. That power was vested in An Chomhairle. I wonder if it is necessary in the light of that to introduce new legislation now to cater for the changes brought about.
With regard to health contributions, it is long past the time when the health boards got out of the business of collecting revenue, particularly since those with medical cards are not obliged to pay some of the levies. It is ludicrous to have the health boards collecting not alone the health contribution but also the 1 per cent employment levy and the 1 per cent tax levy. This is not the function of a health board. Another committee has been set up to decide whether that is right or wrong. I believe everyone will agree this is not a function of health boards and an alternative should be found. This year health boards will find themselves in serious difficulty in trying to collect money because the method of collection and the liability for the amount varies. The health boards have a different set of criteria from that of the Revenue  Commissioners and this causes a further problem for the health boards.
The Minister's statement is interesting more from the point of view of what it did not contain then what it did contain. Our responsibility here is to ensure we provide proper health services. Because of their strict monetarism this Government are not in a position to do that and it is not enough to hide under the umbrella of what the WHO prophesy may happen by the year 2,000.
Mr. G. Mitchell Mr. G. Mitchell
Mr. G. Mitchell: There are a few salient points I should like to raise on the question of the reorganisation of health boards. I have a particular interest in this area having been a former Fine Gael spokesman on health boards. It is an area which calls for particular attention. Even a cursory examination of the statistical information in relation to health boards for 1982 shows a worrying trend in their development. Between them they spent £489 million in 1980 and somewhere in the region of £500 million in the most recent years' accounts. For example, the population within the catchment area of the Eastern Health Board which stood at 841,000 in 1961 had increased to 1.194 million in 1981, which shows that in 20 years it had grown by almost one-third. Comparable figures for the North Western Health board are 200,000 in 1961 and 208,000 in 1981, an increase of 8,000. For the Western Health Board the relevant figure in 1961 was 332,000 and in 1981 341,000. While the Eastern Health Board area geographically is the smallest, in terms of population it is by far the largest and is almost as large as all of the other health board regions put together. Not only that but it must be remembered that in the 20 year period between 1961 and 1981 there was a growth of approximately 30 per cent while in other regions the corresponding growth was less than 10 per cent.
It will be seen from those figures that the Eastern Health Board area accounts for the lion's share of the population, approximately one-third. In turn, this means that growth in some areas has divorced the health services administration  from local administration, giving it a remoteness which was never intended in the original legislation. At this stage in the evolution of health boards, their role, geographic area, composition and activities all should be thoroughly reviewed and reformed. I should like to see a breakdown of the Eastern Health Board, which is not catering for local health difficulties obtaining within its catchment area, in particular within Dublin, Kildare, and I think Meath accounts for the remainder.
The staff increase in health boards of 46 per cent between 1974 and 1981 demonstrates the extent of growth within these health boards. But there has not been a similar penetration within the community of availability of services. Despite the fact that there has been an enormous increase in staff— from 40,000 to 58,000 between 1974 and 1981 — there is still an absence of community relationship which was intended in the original re-organisation of the health boards. This could be overcome by the strengthening of district health committees within the health board areas. I should like to see these district health committees being given greater powers. I should like to see local elected representatives and representatives of other interest groups on those committees feeling they had an input to make, which would be taken seriously rather than the talking shop it is felt they now represent. These district health committees have a great role to play in dealing with some problems confronting the community. The Minister this morning referred to hygiene. If these district health committees were given a proper role, that is one area in which they could demonstrate their ability.
I might make one other point in regard to the health boards, that is in relation to the Trident Report on the review of arrangements for the supply of drugs and medicines. There are a number of recommendations contained in that report. Indeed, the Department of Health are not short of reports and reviews of committees on all sorts of details relating to the needs of the health services. There is one particular recommendation in that Trident Report  to which I might refer: the suggestion of the establishment of a central drugs purchasing agency, constituted perhaps something along the lines of the GMS payments board, a board which would be involved as an agent for the Government in the purchase of drugs centrally. The Trident Report estimated that, if this could be arranged, it would save the State £10 million in 1977 terms. That recommendation has not been pursued. In 1983 terms, heaven only knows what the figure would be, but certainly it would be in the region of £20 million.
This is an area which should be examined and tackled without further delay because it constitutes a scandalous waste of public funds on the purchase of drugs. For example, if drugs are purchased in volume by an agency of the State, that agency would expect and obtain discounts on their purchases rather than the situation at present obtaining in which the various health boards purchase drugs for themselves when, because of the lesser volume, they do not receive the same discount. Therefore, the sooner that recommendation of the Trident Report is adopted and implemented, the better; and it cannot be too soon. I would ask the Minister to take particular note of that recommendation.
I want to say something about accommodation for mentally handicapped adults. We are great people in this country for paying lip service to the mentally handicapped and the various groups within our community obviously in need; but very little, if anything, has been done for mentally handicapped adults within the community. When they reach a certain age, whether they be male or female, it is found that there are no facilities provided by the State for them to meet their specific needs. In many cases, in Dublin especially, they may end up in a special section of one of the mental hospitals, where they should not be. They do not have what might be termed mental problems; rather their problems emanate from their handicap. Some of them may not develop beyond a certain age — perhaps having the mentality of a four or five year old — but they do not suffer from the same type of mental problems  as do other patients in mental hospitals. They are mentally-handicapped adults and the facilities which should be provided for them simply do not exist.
This is something which needs to be examined and dealt with as a matter of urgency. It should be remembered also that these people cannot form pressure groups, they are unable to parade outside Leinster House or anywhere else. Anyhow, we should not be responding to people exerting pressure. Rather should we be responding on a compassionate, caring basis, on the basis of need. These people comprise one section of the community greatly in need: mentally-handicapped adults who have been discriminated against, who have not been catered for and we need to take a very special look at their needs.
I might mention now the assessment of hospital needs on an objective basis. There is reason to believe that within the Dublin region certain hospitals have done better out of the Department of Health budget than have others, not on the basis of objective assessment but rather on the basis of political clout, political know-how or the political backstairs. Probably it has been all right for those of us in whose constituencies hospitals have been facilitated, but that is really not the way to allocate health resources. There is no doubt that there are some hospitals within this city which have done better out of the health budget because of political contacts, whereas others, in equal need, have not been receiving their fair share of the budget because of lack of such political contact or know-how. This is no basis on which to apportion a health budget. It is a scandalous situation.
St. Ultan's Hospital has been closed. There has been a transfer of its services, in the main, to Our Lady's Hospital for Sick Children in Crumlin, in my constituency. As a member of the board of that hospital I believe that it has not been given its proper share of the budget. It has not been treated fairly. It is one of the most advanced children's hospitals in western Europe, but on a visit to the hospital with the Minister for Health we were shown lighting equipment in a surgery  which moved during an operation. All that could be done was to move the operating table with it. This happened in one of the most advanced children's hospitals.
That hospital has not been getting its fair share of funds and has not been able to modernise. The staff are keeping up their traditions and standards despite the lack of funds, but if the hospital got its fair share one can imagine what it could do for children. If there is to be a greater transfer of child patients to the hospital as a result of the proposals regarding St. Ultan's Hospital, will they be given a larger budget? Will they be given the facilities to do their job? They have a dedicated staff but they need the necessary finances. If not, will the Minister tell us why during the last few years they have not received the same kind of recognition as has been the case with other hospitals on the north side of the city. There is something seriously wrong in the way the budget allocations have been made to hospitals. I do not accept that it has been done down the line on an objective basis or on the basis of a fair assessment.
In my constituency there is an enormous problem with regard to drug abuse. About a year ago I attended a meeting in my constituency. A lady came in and threw on the table a bag of syringes and used needles which she said she had collected in one afternoon in a block of flats. I am aware that steps are being taken to deal with the drug problem and it is not a minute too soon. What happens in many areas, particularly in the inner city where there is high unemployment, is that people move in and get the local people hooked on heroin by giving it to them for nothing in the first instance. When people become hooked on the drug they push it on others. Many of these people commit crimes to pay for drugs.
Despicable and heartless crimes have been committed. I have no doubt that the normal rigours of the law do not and should not apply in such cases. These people roam the streets trading in misery. Others in the community know who they  are, or say they know, but they are terrified to point a finger at them because they fear for their safety. The misery caused by drugs hits at the heart of the community. Extraordinary efforts and extraordinary powers are necessary to deal with the problem. Legislation on its own is not sufficient. There is legislation on the Statute Book for the punishment of drug pushers. I think it is time we asked ourselves whether these people are outside the normal laws and, if so, should extraordinary powers be taken to deal with them? These people are not just out to commit petty crime. Their aim is to make themselves very wealthy at the expense of the health and future of our young population. It is time we examined whether the normal procedures of the law are adequate to deal with them and to consider whether we should have some emergency powers to deal with the godfathers of drugs in our community.
I welcome the proposed developments in the community services, particularly for the aged. In the Crumlin area on the old Lorcan O'Toole park caravan site there is a new small housing development by Dublin Corporation for senior citizens. Normally this development would incorporate a common room. As a result of intervention by all public representatives, by the group involved in running the centre, the Eastern Health Board and Dublin Corporation it has been agreed that the community centre for old people in this area will be extended. It is proposed to pay for that extension by way of a contribution from the Eastern Health Board to the corporation. In the extended centre there will be facilities for a physiotherapist, a nurse and a chiropodist, who will be available not only to the people living in the flats but also to people in a large catchment area who come to the centre for meals. This is a welcome development. It is making good use of State resources and it shows commonsense on the part of the Eastern Health Board and Dublin Corporation.
I should like the Department of Health to draw up guidelines, if necessary with the Department of the Environment, for similar developments throughout this city and the country. Senior citizen flat complexes  are usually quite small and there could be an extension of the common room in each centre in order to provide the facilities needed by old people on the lines set out by the development at Crumlin. These services should be provided on a community basis rather than keeping them solely for the tenants of the flats. With the co-operation of local authorities and the health boards this could be achieved. I hope the development on the Lorcan O'Toole site will be a prototype for similar developments generally in the community.
I wish to raise a particular point with regard to a constituent of mine. This man had three young children and his wife gave birth to triplets. He was living in a two-bedroomed flat. In that kind of situation the Department of Health and the health board have a special responsibility. For instance, there is no additional tax allowance for a man in that situation but I think there should be some special help in a case like this. I know that it depends in many cases on the CEO of the health board, but when people find themselves in an unusual and difficult circumstance they should be able to get an immediate response from the board. There should not be form-filling or long delays in helping them. There is no doubt that a man living in a two-bedroomed high rise flat with an income of £110 per week, with three children, and suddenly with six children, is in need of special help. The health board should be able to give immediate assistance is such a case.
When the Minister is replying perhaps he will let us know the up-to-date position in his Department with regard to vaccinated children who have suffered brain damage. Many people believe there has been a cover-up with regard to this matter. They may not be entirely right but there is reason to believe that the length of time it has taken to bring this problem to a head has been outrageous. The State should come clean with regard to its responsibilities in this matter. They should look at what was done in the United Kingdom for similar brain-damaged children and make the same type of arrangements for compensation to the families. That compensation should be generous. If the State has a responsibility  in the matter it should accept it. It should not expect parents who cannot afford the high medical expenses involved to pay for them.
I should also like to make a special appeal in respect of asthma sufferers. This is a particular group who do not get much recognition from the State. They are not covered by any of the long-term illness facilities. I ask the Minister to give particular consideration to asthma sufferers. Perhaps he would consider the suggestions of the asthma society. I will come back to this aspect of asthma in some future health debate and deal with it in greater detail.
Despite what Deputy O'Hanlon, the Opposition spokesman, said, there are some abuses of the general medical services scheme. There is reason to believe that repeated visits to doctors are not always justified. The blame may not rest entirely with the doctors; people insist on coming back and perhaps they feel more confident and at ease with themselves after visiting the doctor. However, there is no doubt about the enormous problems in this area. In a similar scheme in Britain visits to the doctor average about 3.6 while visits in Ireland are on average 6.3. almost double the British average. There is something terribly wrong here. It is worrying that at least one doctor under the general medical services scheme was paid last year more than twice what the President of Ireland was paid. People may say that the doctor may have had other people working with him in the scheme but I do not accept that. That amount was received by him out of the GMS practice, leaving aside any private practice he may have.
That is scandalous. People are being taken for a ride. The taxpayer, the PAYE man, had to march down the road there some weeks ago because we have reached saturation point on taxation. We must have a look at expenditure, and payment to doctors under this scheme must be examined. If there are to be cutbacks in expenditure let us look at this area where obviously there are abuses. The State cannot afford the luxury of keeping doctors — not all doctors of course; I do not want to be taken as attacking the medical  profession — at that level of pay. Most doctors regard their profession as a vocation and are very dedicated to it. Those who are abusing this scheme should be told that this will not continue and the sooner that is done the better.
Another problem is that 80 per cent of visits to doctors lead to medical prescriptions. In many cases tablets, for instance, may not be required but are prescribed because the doctor feels that the patient perhaps requires some medication. With the fee and the prescription in such a case the State is being taken for a ride here. About a year ago the amount involved in this was estimated at £28 million and I suppose the current estimate is something like £30 million. This, together with the money being spent on GMS drugs and services and what is being lost according to the Trident Report could represent up to a £50 million saving in the Estimate for the Department of Health if this matter was dealt with in a proper manner.
If the Department of Health continue along the road they have been going we will have to say that we do not want a cutback in services, we do not want to penalise people, but abuse and outrageous overspending of public funds cannot continue. The taxpayer cannot afford to allow Government Departments — in this case the Department of Health — to continue to live beyond the taxpayers' means, and that is what it amounts to. When the public expenditure committee are set up I hope they will examine this area. The cost of the GMS scheme in 1973 was £14.1 million. In 1983 it is in the region of £85 million. That is a huge increase in ten years. This area should be given immediate attention by the public expenditure committee and the sooner this House looks at and sanctions the Estimate for the Department of Health before it is spent, the better.
The Minister mentioned the question of consultants using hospital facilities and Deputy O'Hanlon referred to this also. I would like the Minister to extend that to comment on doctors in certain cases using health board centres. We would like to facilitate everybody and give free  availability of these services to all if that was in the interest of the community, but scarce resources must be applied carefully and paid for. We must examine the question of doctors in health centres.
Within the Dublin region approximately 20 per cent of the population are in receipt of medical cards. In Donegal about 65 per cent of the population have medical cards, that is proportionately three times as many as in Dublin. About 200,000 in Dublin and 80,000 people in Donegal have medical cards. I accept that Donegal has difficulties and I do not want to pick Donegal out of other regions in the country. However, Dublin also has difficulties and the inner city in particular has big problems. The disparity in the allocation of medical cards needs to be examined. Certain citizens are given advantage over other citizens who are equally badly off. That is not fair. I ask the Minister to look at the question of the distribution of medical cards and to consider why 65 per cent of the population in Donegal are in receipt of medical cards as against only 20 per cent of the population of Dublin. I accept that the needs of some areas are greater than those of other areas but I do not see why the disparity is so great. People are being denied medical cards in the Eastern Health Board area, particularly in Dublin, because their income is £1 or £2 over the limit which qualifies them for the medical card. The rule is applied very rigidly here but I suspect that it is not applied equally rigidly outside the Eastern Health Board area.
An aspect of the health board GMS scheme that I want to mention is the distribution of drugs on a generic basis rather than a brand basis. Drugs are being prescribed on a brand basis and this is increasing their cost to the user, the taxpayer, via the Department of Health Estimate and the local health board. A great saving could be effected if generic drug prescription was the order of the day. That together with volume purchasing, to which I have referred, would tend greatly to savings in the Department of Health.
I have heard suggestions that items obtained through the GMS are being  used as trading stock by some street traders. It is alleged, perhaps the Minister could say if this is true, that in the past some people who got prescribed items such as Pampers would exchange them at the chemist for a different item to the same value. It is also alleged that many of these items are trading stock for people who are selling at the side of the road. I have no hard evidence to support that statement but perhaps the Minister has evidence to indicate that this is the case, and, if so, what steps are being taken to ensure that this sort of abuse will not continue?
There is also a suspicion with regard to drug abuse, that a very small minority of doctors are not being as careful as they should be in the prescription of drugs and also in the prescription of non-drug items. I am sure the majority of the medical profession are concerned about this. Given the drugs problem which exists in the city, the Minister, together with the medical profession, should consider introducing, as part of a multi-pronged attack on the drugs problem, stricter regulations in relation to practitioners who are not particularly careful in prescribing drugs, especially drugs which are constantly being abused. A review of the severity of penalties for any person who wilfully, negligently or even carelessly prescribes drugs which are being used by people in the area of drug abuse is urgently needed. The regulations in regard to penalties against such people should be re-examined in the light of the existing problem.
The Minister should also consider what action, if any, is required against pharmacists who are caught supplying goods quite different from those which have been prescribed. Given the state of the public finances, the Government must bring home to people in the GMS, whether they are doctors or pharmacists, the fact that the State can no longer afford to continue some of the past practices and that anyone caught supplying goods different from those prescribed will be dealt with very severely.
In most hospitals — and this is not confined to Dublin — there is a very long  waiting list for certain orthopaedic operations. These operations are usually performed on older people although, of course, younger people may also require them. I have had people coming along to me with bad hips asking if anything can be done to speed up their operation. When I telephoned the doctor, I found that they were not exceptions, that there are quite a number of people, some of whom may be in pain or confined indoors, who are also awaiting operations.
I note the Minister has made arrangements to appoint a number of consultant orthodontists to the health boards and I should like to hear more details as to when they will take up their appointments. I should like similar appointments to be made in the area of orthopaedics so that the waiting list there can also be cut down. I thank the Minister for his detailed comments with regard to the health services and I ask him to reply to the various points made by me.
An Leas-Cheann Comhairle John J. Ryan
An Leas-Cheann Comhairle: I should like to remind Deputies that, by agreement, the debate on this Estimate will conclude at 5 o'clock.
Mr. Faulkner Mr. Faulkner
Mr. Faulkner: I should like to comment on the care of the mentally handicapped. During the course of my public life, I have always regarded it as a privilege to be associated with mentally handicapped people, those who care for them and who assist them in any way. I am naturally pleased, looking back over a relatively long time as a Member of this House, to see the considerable advances which have been made in the care and education of the mentally handicapped and in the changed attitudes of the public generally towards those who are mentally handicapped.
There is now an acceptance of the fact that it is not a stigma to have a mentally handicapped child. It is perhaps difficult to believe that, during my early days as a member of the Dáil, it was regarded by many as a stigma, and parents were loath to permit a mentally handicapped child to be seen in public. The question of providing education for such children was  not even considered or believed possible, except by some religious orders and voluntary organisations. I knew then that there was mental handicap but I did not know much more about it. As far as I can remember, I had seen only one severely mentally handicapped child prior to my entry into public life. This was the situation in relation to the public generally at that time and, if such circumstances continued to prevail, quite clearly no progress could have been made regarding the care, attention and education of the mentally handicapped or in respect of the amelioration of the problems and difficulties facing the families of mentally handicapped children.
Against such a background, the progress made in a very short space of time has been very good but much more remains to be done. I have pointed out that only a few years ago the general public had little or no conception of the problems and difficulties of families with mentally handicapped children. Indeed, they hardly knew such children existed. This, however, does not mean that nothing was done to help. As I mentioned, religious orders were doing trojan work in this sphere under immense handicap. It was through one of these Orders, St. John of God Brothers in St. Mary's, Drumcar, in my constituency, that my interest was first aroused in mental handicap. I remember, many years ago, speaking in this House on the subject in an effort to help to overcome the first great obstacle on the path to progress, by endeavouring to persuade families in which there was a mentally handicapped child to appreciate that mental handicap was not a stigma, that it could occur in families of the rich as well as those of the poor, in families who were highly intelligent as well as in families with relatively low IQs.
Having seen the excellent results of the Brothers' training methods, I was anxious that parents should recognise that much could be done to develop the capabilities, few though they might be, which God had given to these children. I have always been a great believer in the capacity of our people to respond in a positive  manner when they came to understand and appreciate a problem and the need for their involvement in efforts to overcome it. The public gradually became aware of the position and so helped to achieve much by voluntary effort and, to even greater effect, began to put pressure on Governments to assume responsibility in this area. There are now schools for mentally handicapped all over the country but in my early days in the Dáil the Department of Education would not recognise trained primary teachers in schools for mentally handicapped children. They would only recognise them if these children attended primary schools which were unsuitable for this purpose.
A young teacher teaching in a primary school in County Louth decided, when the St. John of God community in St. Mary's set up a school for the mentally handicapped, that she would transfer to that school. She was informed by the Department that if she did so they would not pay her salary. It is very much to her credit that she transferred and for quite a considerable time depended on the salary which the brothers could afford to pay her. This situation has changed very considerably, quite possibly through her decision and the efforts made to have her recognised by the Department.
I mention these matters simply to show what has been achieved in relatively recent times in providing for mentally handicapped children and is going some way towards giving them the rights to which they are entitled as citizens. We must remember that treating all our citizens equally applies to the mentally handicapped. However, we must go much further if we are to treat our mentally handicapped brothers and sisters as we should treat other citizens, particularly if we are to cope with the needs which have resulted from changes in the field of medicine.
Bringing the problem into the open helped and also its acceptance by the public generally. That ensured Government concern and involvement which continued to the complemented by the help and assistance already available within the community from the religious and voluntary organisations. Government  involvement helped in quite a considerable number of ways, for example in the educational field and in the provision of finance for a variety of services, as well as capital for buildings and so forth. The public recognised the problem as one which had to be tackled, and displayed a willingness to pay taxes and to contribute on a voluntary basis to try to ensure the success of the efforts being made.
Much has been done to create a better understanding of the mentally handicapped person, in diagnosis, early intervention and early placement for social training and special education. However, there is still a lack of community awareness in a different sense. As a people, we are not prepared to the extent that we might be to accept mentally handicapped people into the community and to recognise them as being of the community. We still tend to treat them as separate from it. However, the traditional pattern of residential centres catering for a person from the cradle to the grave appears to be changing. This provokes a certain fear in parents, but also a fear in the community because they recognise that they will be asked to accept responsibilities and commitments which heretofore have been the role and function of the residential centre.
If we are to keep pace with newer, positive concepts such as community integration, normalisation and humanisation, we should carefully study and examine these concepts. Up to some years ago, it was the practice to remove the mentally handicapped child from the family and place him or her in a setting usually removed from the local situation and, indeed, very often the system even discouraged family community relationships. Now it is suggested that we reverse this trend and some would have us eliminate all centres which were once thought necessary. This is perhaps too idealistic but these concepts which have given rise to new initiatives must be studied and much thought given to educating parents and the community at large in the process. In all this, we must concern ourselves with the dignity of the mentally handicapped person and the State and the community at large must gear themselves to  creating a psychological, sociological, familial, educational and legislative process in order to create the environment which will result in the complete development of the mentally handicapped person within our society.
I have little opportunity, because of the constraints of time in this debate, to develop this theme as I would like. Let me simply say that integration must include commitment by all of us to assist mentally handicapped people to full citizenship in accordance with their capabilities in the sphere of family life, the school, vocational training, employment opportunities and, in a more general manner, in the social and cultural life of the community. Normalisation implies that every person in the community must ensure the complete rehabilitation of the mentally handicapped person using all the means available, and in cases where that proves impossible because of the nature and severity of the handicap, to achieve a working environment which resembles as far as possible the more normal model. Through these processes of integration and normalisation there emerges a spirit of humanisation which emphasises the dignity, welfare and total development of the mentally handicapped boy or girl.
More remains to be done through continued education of the public at large, because it is only through persistent efforts that attitudes will change. I mentioned the changes brought about by the development of medical science. It is not many years since the majority of mentally handicapped people barely lived beyond the age of 21 years. Because of the advance in medical science, this situation has now changed completely and mentally handicapped people are living to a relatively old age. Two major problems which did not arise in the past now face us because of these changes. The first is how to deal with the adult mentally handicapped person in respect of facilities for him or her, further education, the provision of work and so on. The second is how to cater for young mentally handicapped children, places for whom would have been available in the past because of the short life span which was then the  norm, but which are now no longer available because of the dramatic change in the life span.
We badly need a national and regional policy for the adult mentally handicapped. Facilities and services must be provided for these, not solely in the national residential system but rather, where possible, in integrated and community-oriented services. We need more hostels and group houses. Local councils should consider making houses available for such purposes. Mildly and moderately mentally handicapped people could be facilitated in this way and given the key of a house where the minimum of supervision would be exercised. Parents are often very concerned about what will happen when their mentally handicapped child reaches the age of 18 years. They want to know what security there is for their child. As time passes they become more anxious and are understandably distressed because of the bottleneck in the residential area.
We do not have a complete national policy for adult mentally handicapped people. We should concentrate our efforts on rethinking the present position and preparing for the future development of adult services. We speak of the dignity of the individual but in our planning in this area we are more concerned with the collective situation. Many of these adults have spent a quarter or half of their life in an institution away from a family environment. They are then asked to live a new lifestyle in a community setting.
Since the late fifties work experience for the more capable has tended towards industrialisation, bringing to the workshops mass production techniques with resulting dehumanising effects. Less emphasis has been placed on the social and cultural skills. We should have a look at the traditional work patterns and rethink the whole situation. As Deputy O'Hanlon said, in Europe skills in horticulture, husbandry and farming have been introduced as alternative work. In our traditional agricultural community we could direct the energies and skills of a high percentage of the mentally handicapped  into these areas. Where projects of this nature are in operation the young people are delighted with them.
In the past many of those who reached adult age had nowhere to go and were placed in psychiatric hospitals. It has been mentioned by many speakers that none of these were mentally ill patients. It was wrong to send them to such hospitals which did not have facilities for them. The hospitals were not suited for the long-term care of the mentally handicapped. However, because they have nowhere else to go they stayed there for the duration of their lifetime. For this reason the atmosphere of the special residential centres for the mentally handicaped should be simulated as closely as possible to a psychiatric hospital. This would involve segregating the mentally handicapped from the mentally ill, providing special trained staff to care for them and providing training and education.
Our psychiatric hospitals have been the subject of much discussion and criticism as regards the mentally handicapped. However, it must be recognised that much progress in the social training of the mentally handicapped resident has been made in a short space of time in these hospitals. Money has been made available and many old buildings have been reconstructed to facilitate the mentally handicapped. In my constituency St Bridget's Hospital has its own unit.
While one readily recognises that the psychiatric context is not the ideal one for the development of the mentally handicapped no matter what high standards obtain, the fact is that a minority group of the handicapped population will need the added therapeutic expertise of the psychiatric service if they are to benefit from the newer concepts of integration, particularly since there are no specialised units in the larger hospitals to cope with the mentally handicapped person who has a psychiatric disability. The increase in the adult population in the centres is creating its own problems and denying the right of some of our mentally handicapped to early training and placement. Parents of such children do not have the satisfaction of early integration,  early training or placement. When they are placed the children are often separated by great distances from their parents. Parents try to keep in contact with their children over the years but at what sacrifice and difficulty is know only to them.
If we are to cope with the problem of the adult mentally handicapped we must have a rationalised policy and pursue the possibility of accommodating young adults in hospitals and group homes and, where possible, of repatriating them. Included in this adult population is a certain percentage of emotionally disturbed adolesents and adults which creates a strain on an already strained personnel. It may not be understood that the ratio of staff must be greater than what is deemed necessary for other groups if the specialised care and attention which is their due is to be given to them. Centres must not be allowed to deteriorate into providing custodial care only. I refer to some problems arising from the introduction of the new syllabus required by An Bord Altranais in respect of the training of nurses to cater for the mentally handicapped. Its introduction resulted in significant improvements in that it required a student to spend a greater time studying and gaining experience of other aspects of the discipline. This must be accomplished with the same level of staff as was the case when student nurses followed the old syllabus. This has severe implications for the nursing services.
I might also point out that the percentage cutback in staff is also creating a problem and the fact that, for example, nine nurses are on maternity leave and the centre is only permitted to employ three to replace them also gives rise to problems. Unless steps are taken to remedy the situation the quality of life for the mentally handicapped is in danger of being eroded to an unacceptable standard. This aspect should be appreciated by the authorities and remedial action taken soon to remedy the position.
The rights of every individual are enshrined in our Constitution. It is well to remember that our citizens include those who are mentally handicapped. Institutions which deal with the mentally handicapped regard each person in the  fullness of his being and not just as a number in an institution.
Dáil Éireann 343 Estimates, 1983. Vote 48: Health.